Cardiology Potpourri (Tsai, 5/11/2022)

Thanks to our speaker this week, cardiologist Dr. Joanne Tsai, for an excellent review of cardiology topics for outpatient care of cardiology patients, particularly regarding Atrial Fibrillation and Atrial Flutter.  

A recording of her presentation is available HERE. 

My notes:

• When in doubt, get a 12 lead EKG
• That being said, accuracy of EKG interpretation is shockingly poor:
• 42% for med students, 55% residents, 69% primary care, 75% cardiologists
• It is super important to provide clinical framework for the EKG reader; clinical information definitely increases accuracy
• The most common errors with computerized EKG interpretation occur with sinus arrhythmia (computer only accurate 55% of the time) and AV nodal conduction disturbances (2nd, 3rd degree AV block)

pseudo atrial flutter

CHA2DS2-VASc scores

CHA2DS2 stands for (Congestive heart failure, Hypertension, Age ( > 65 = 1 point, > 75 = 2 points), Diabetes, previous Stroke/transient ischemic attack (2 points). VASc stands for vascular disease (peripheral arterial disease, previous myocardial infarction, aortic atheroma), and sex category (female gender) is also included in this scoring system.

Reliability of CHA2DS2-VASc scores

• "C"=in the CHA2DS2 stands for CHF; however, guidelines are quite vague in the case of  HFpEF and whether CHF should be considered if pt history vs. symptomatic
• Of note, people with OSA have higher risk of stroke (compared to people without OSA), so assessment for OSA is of utmost importance

CHA2DS2-VASc scores predict MACE=Major Adverse Cardiac Events (whether or not you have Atrial fibrillation). In fact, CHA2DS2-VASc score >4 puts you at particularly high risk for cardioembolic stroke, even in the absence of AFib.

Atrial Fibrillation 

• Lifetime prevalence of developing AFib for a 40 year old in the US is 1 in 4 (compared to breast cancer 1 in 8)
• overlap between Afib and OSA is 80-90%
• it's really important to get patients with HFpEF into sinus rhythm (and out of AFib)
• even though the AFFIRM trial found that rate control> rhythm control, Dr. Tsai argued that most of these trials excluded people with HFpEF
• that for patients with AF and  HFpEF, we really need to put them into sinus rhythm, including anti-arrhythmics
• weight loss is associated with decreased CV mortality in A Fib

Evaluation for AFib/AFlutter

• TTE (looking for ejection fraction, evidence of genetic disorder e.g. hypertrophic cardiomyopathy), EKG (looking for prior infarct, LVH, evidence of genetic disorder), sleep study (looking for OSA), ischemia evaluation 
• Don't forget exogenous toxins (e.g. alcohol-- direct cardiogenic effect at the level of the atria)

Who should get oral anticoagulation regardless of their CHA2DS2-VASc score?

• hypertrophic cardiomyopathy
• hyperthyroid (especially when actively thyrotoxic; once no longer some will stop anti-coagulation; others continue because still hypercoagulable)
• moderate-severe mitral stenosis
• mechanical heart valves

Syncope: history building (vs. history taking) 

• getting a good history regarding the loss of consciousness can determine cause 90% of the time without any testing
• face to face conversation, ask open ended questions
• "How many times have you passed out/lost consciousness?"
• Calculators for syncope evaluation:
• San Francisco Syncope Rule
• Dr. Tsai prefers the  EGSYS (Evaluation of Guidelines for Syncope Study)